Barrier to Entry

August 2, 2014

I’m about to get myself in big trouble here. In another excerpt from what is rapidly becoming a book-length project on choosing nursing vs. medicine, I’m going to try to tackle part of nursing’s image problem. Hold onto your hats.

Here’s a quote from a reader of this blog:

“I have done a semester of an RN program, but I’m starting to have an identity crisis. If I worked harder in the past, I would have been going to medical school today.”

What this person is really saying is: “Doctors are better educated than nurses. So if I’m smart and good in school, I should be doctor. If I don’t work hard or get good grades, I should be a nurse.” First of all, the term “better educated” is fairly meaningless. By “better educated” do you mean smarter? Good nurses are smart, and I know plenty of dim doctors. By “better educated” do you mean “spent more time training?” Time in training gets you more experience, not more education necessarily. By “better educated” do you mean “spent more time in school”? I spent a whole year sitting in Calculus and never learned a darn thing. Yes, doctors have more education, of a scientific and medical nature. That’s why they get to make medical decisions.

What the writer might really mean by “better educated”, “better” being a value judgement in this case, is “superior”. Herein lies one of the core sources of nursing’s image problem and it’s tendency towards defensiveness: the assumption that “Doctors are superior to nurses because they are smarter and better educated.” This is what people who say “You’re really smart. You should go to medical school” are really implying. I hope by now you know that I think that the decision to go into nursing or medicine lies in what you want the focus of your care for people to be, and not how smart or educated you are or want to seem. But the the assumption that doctors are smarter than nurses persists, in large part because of the barrier to entry.

Let’s compare the academic bar set for various degree programs.

Admission requirements for a typical ADN program:
1. Be high school graduate or have passed the high school equivalency GED (General Educational Development) Test.
2. Have a high school grade point average (GPA) of at least 2.5.
3. Have completed one-year courses in high school algebra, biology and chemistry with “C-” or higher in each.
4. Have a negative 7-panel urine drug screen and complete a criminal background check. Students will not be allowed to enter the program until cleared by GRCC police.
5. Score at least 75% on the HESI test. This test assesses knowledge in reading, vocabulary, grammar, and math.

Here are the entrance requirements for a typical state medical school:
1. High school diploma with average science GPA of 3.7 and total GPA of 3.8
2. College degree with all the required science and math courses (grades of C or below don’t constitute completion of any any course), average GPA 3.7
3. MCAT scores of at least 27

The existence of an entry point into nursing that does not require a college degree, or even a high school diploma, really, and that only requires the student to barely pass their coursework, pulls professional nursing into the realm of being more of a job or a trade than a career, requiring more brawn than brains. An ADN-prepared nurse might be a great nurse and a smart person, but such a low barrier to entry fuels the assumption that nurses are not smart. Nursing policy makers would really like to make a college degree a requirement, but there is also a strong argument being made that removing the ADN as an option will discourage people from becoming nurses at all. Professional nursing will have to decide whether it wants to maintain this inclusivity at the expense of image and credibility.

Medicine, of course, has an incredibly high barrier to entry, both in terms of time, money, and academic ability. Notice I don’t say intelligence. Medical school is more about persistence than smarts. But to become a doctor you have to perform at a very high level for a very long time from a very young age. And it’s very expensive. It almost seems designed to discourage people from becoming doctors. The resources, both external and internal, required to actually complete such a road are beyond what most people think they can come up with. This lends to medicine a mystique and unreachability that results in a superior image.

I’m not saying that nursing should require everyone to have a PhD. Nor am I in any way saying that doctors are smarter than nurses. Nor am I saying that ADN-prepared nurses aren’t good nurses. I’m saying that the standards set by educators and administrators in any field should reflect the image that field wants to portray.

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I don’t know what nursing schools you are referencing, but that’s not the case for ANY of the schools in AZ. Yes, you have to have a decent GPA in high school. BUT. You also have to have taken ALL of the prerequesites and gotten at least a B. This includes College Algebra, College Biology, the entire year of Anatomy and Physiology, Microbiology, Psychology, English 101 and 102, and a sociology class. You can’t even apply unless you are currently in the last of these classes (usually A & P II). GPA’s are taken into consideration along with HESI test scores, and I’m pretty sure someone with a 75 wouldn’t even be considered for a nursing program here. Competition is TOUGH. Most of the people I know that are currently in nursing school had 4.0 GPA’s before getting in.

I’m sure you are correct. I was using the documented requirements for various ADN and BSN programs on the programs’ websites, not data on who actually got accepted. And I am not referring to BSNs when I talk about barrier to entry. I think professional nursing would be well served to require a BSN.

I dont think you got yourself into trouble. If I saw emotionalism in it, I would agree. You were attempting to compare entrance type requirements,etc. I don’t feel that a scientific type of comparison is a problem.

I think you were extremely wise in saying intelligence for MD was left out. I would disagree in that I think you do have to have some smarts to get in. I think the issue, at times, is emotional intelligence & maturity.

With all due respect, my parents could never understand how someone like me could make A’s in physics, take an extra year of math, but have the common sense of a fish. At times, they were dead on the money.

At other times, sometimes tis best to keep quiet. Like when they got into a problem and couldn’t balance their checkbook. They didn’t want me to have one, being a senior in college. Well I laughed, how hard can it be? They were in the hole for over 200 quid.

I believe that the image of nursing suffers from lack of required entry into nursing being at least a BSN. The question is not intelligence, capability or technical savvy. It’s about image. It a job field wants to be portrayed as a profession and possess a career ladder based upon educational advancement and outstanding performance, a higher degree needs to be achieved. In the military, officers wear rank which does not differentiate between doctors, nurses, pharmacists or other degree holding individual. An enlisted member may hold high level degrees and their rank increases accordingly. They are rewarded. In the civilian sector, a nurse is a nurse. Same pay, same position regardless of education and/or experience. I don’t tell people I’m a nurse lest I say something stupid and confirm their suspicions.

In any field of work, there is an expectation of some level of education. Certainly a nurses aide could give you high quality care but they have limitations on their scope of practice. Many nurses leave the job field because of lack of respect, poor working conditions to include lack of working or available equipment, poor pay, no career ladder, long hours without breaks for bathroom or eating, being responsible for all aspects of each patient’s care with none of the authority. All that with the expectation to provide quality care with a great attitude.While that image suits you just fine as ‘the public’, for those of us in the trenches, that is not acceptable. Improving the image of nursing to reflect it’s value in the healthcare world, improves working conditions thereby improving staffing and making quality patient care more likely.

When it comes to professions, image is incredibly important, as Jenn says. High-level training and certification requirements are essential for validation as a profession, and educational level and expertise are inherent in that. As far as “the public” goes, patients give great weight and attention to titles and qualifications, regardless of actual quality of care. Patients who insist on “Attending only” anesthesia or who mistrust CRNAs, anyone who has ever considered their primary care visit suboptimal because a nurse practitioner cared for them, and any doctor who has been asked “how many times have you done this?” are prime examples of the degree to which people pay attention to “image”.

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